Nokea
A nurse is assessing a newborn whose mother had gestational diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
- A. Hypertonia
- B. Jitteriness
- C. Acrocyanosis
- D. Generalized petechiae
Correct Answer: B
Rationale: Jitteriness is a common sign of hypoglycemia in newborns. Other signs may include irritability, poor feeding, and lethargy.
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A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. Which of the following medications should the nurse plan to administer?
- A. Digoxin
- B. Calcium gluconate
- C. Vitamin B6
- D. Propranolol
Correct Answer: C
Rationale: Vitamin B6 (pyridoxine) is often used to treat nausea and vomiting in pregnancy, including hyperemesis gravidarum, and is considered safe for use in pregnant clients.
Which of the following interventions is most appropriate for a client with hyperemesis gravidarum?
- A. Encourage high-calorie meals
- B. Administer intravenous fluids
- C. Provide frequent small meals
- D. Limit fluid intake
Correct Answer: B
Rationale: Hyperemesis gravidarum is severe, persistent nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. The priority intervention is to administer intravenous fluids to maintain hydration.
A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?
- A. Baby oil
- B. Antibiotic ointment
- C. Petroleum jelly
- D. Alcohol wipes
Correct Answer: C
Rationale: Petroleum jelly is recommended to prevent the diaper from sticking to the circumcised area, reducing irritation and promoting healing. It should be applied during every diaper change until the site heals.
A nurse is reviewing a client's medical record and notes that the client is taking tamoxifen. The nurse should identify that tamoxifen is used to treat which of the following conditions?
- A. Non-Hodgkin's lymphoma
- B. Endometriosis
- C. Breast cancer
- D. Polycystic ovary syndrome
Correct Answer: C
Rationale: Tamoxifen is an anti-estrogen medication primarily used to treat hormone receptor-positive breast cancer. It works by blocking estrogen receptors in breast tissue, slowing the growth of tumors that require estrogen to grow.
A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?
- A. Contraction frequency every 3 min
- B. Contraction duration of 100 seconds
- C. Fetal heart rate with moderate variability
- D. Fetal heart rate of 118/min
Correct Answer: B
Rationale: A contraction duration of 100 seconds indicates potential uterine hyperstimulation, which can lead to fetal distress and decreased uterine perfusion. The nurse should discontinue the oxytocin infusion immediately to ensure the safety of both mother and fetus.